Wiki Xray diagnosis fall vs early degeneration

[mcrossley]

A patient had a knee xray performed due to pain from a fall (work injury) and the impression mentions early djd and joint effusion. It was charged out with M17.11. Is this correct or should it have been coded with the injury/effusion?

 

[thomas7331]

There is no injury documented here, so you can't use an injury code. I think you could justify using knee pain with the external cause code for the fall since those were the reasons for the x-ray and the provider has not indicated whether the pain is due to the DJD and effusion or from some other source that was not determined by the x-ray. In that case, I would use the DJD and effusion diagnoses as secondary codes for the incidental findings.